At Aravind Eye Hospital in Pondicherry, India, efficiency and sustainability are at the forefront. The hospital offsets its energy bills through solar panels on the roof. Water runoff is recycled through a decentralized wastewater treatment system and used to irrigate surrounding gardens and fields. Food waste from the cafeteria is converted to manure for gardening, and boxes that instruments are shipped in are repurposed to grow plants that are sold in the medical center’s nursery.

“We try not to waste anything,” explains V.R. Vivekanandan, MBBS, a cataract surgeon with the hospital.

This ethos extends to the operating room as well. While Dr. Vivekanandan operates on one patient, another patient is prepared for cataract surgery in the same room. When Dr. Vivekanandan finishes one case, all he needs to do is change gloves and move to the next table. The cassettes and tubing in phacoemulsification machines are not discarded until the end of the surgery day. A 500 ml bottle of balanced salt solution is used for several cases. After each procedure a nurse collects instruments, including phaco tips, for quick-cycle sterilization, ensuring effective reuse. “Small things like this make a big difference,” says Dr. Vivekanandan. “At the end of the day, you save a lot of resources.”

Aravind Eye Hospital has also taken steps to reduce patient transportation, which numerous studies have found contributes significantly to healthcare-related emissions.^1-3 After surgery, patients without complications are not required to travel back to the hospital for follow-up visits. Instead, they can visit a vision center near their home and meet with an ophthalmic professional, while their surgeon checks in virtually via a telehealth link.

Today, methods used at Aravind Eye Hospital and in surgical facilities throughout other low-income and middle-income countries are being held up as good examples for American physicians and ASCs to follow. They represent a growing movement among cataract surgeons worldwide to increase environmentally sustainable practices in the operating room.

Cataract Surgery Is a Major Waste Generator

An estimated 70 percent of waste in the health care sector comes from operating rooms or from labor and delivery units, says Aakriti Garg Shukla, MD, an assistant professor of ophthalmology at Columbia University Irving Medical Center and New York-Presbyterian Hospital in New York. Ophthalmology has the highest procedural volumes of any specialty, with about 30 million cataract surgeries performed worldwide in 2022. That figure is expected to exceed 50 million cataract surgeries a year by 2050.

“We use disposable trays, disposable gowns and so forth, and so if you take all of that into account, we produce a lot of waste,” observes Oliver Findl, MD, MBA, chief of the department of ophthalmology at Hanusch Hospital in Vienna, Austria, and president of the European Society of Cataract and Refractive Surgeons (ESCRS). “Most of the waste—except the actual outside packaging material, which we can try to recycle—must be put into infectious waste, which must be burned.

“We really need to start thinking about what is really necessary, and we need to try to make packages even more sustainable by looking at supply chains,” says Dr. Findl. “Where was that plastic produced? Where was that paper produced? And how was it produced, using what kind of energy?” Countries like Iceland and Norway, for example, predominantly use renewable energy (geothermal or hydroelectric) to produce electricity for manufacturing, he notes, whereas other countries—including China, India, and the United States—use fossil fuels like coal to produce electricity.

Dr. Findl has made some changes in his own practice, using smaller drapes and forgoing drapes for armchairs. He has also eliminated Q-tip swabs from cataract packs because they often go unused. Additionally, Dr. Findl has worked through ESCRS to put more focus on sustainability through a project called SIDICS, which aims to develop a sustainability index for disposable products used in cataract surgery. The goal is to publish the index before the 2023 ESCRS meeting. The idea is that surgeons can use the SIDICS index to check the carbon footprint of their custom cataract packs, so they can choose more environmentally friendly options.

A survey of 32 surgical centers in Austria, conducted by Dr. Findl, found wide variability in the products used in custom cataract packs. If all centers used smaller packs, reducing the weight of each pack to the lower one-third of the average pack, he calculated they could reduce carbon footprint by about 32%. This research has not yet been published.

Find Resources at New EyeSustain Website

In September 2022, ESCRS held a carbon-neutral annual congress in Milan, Italy, through efforts such as encouraging attendees to travel by train instead of airplane, using 70 percent locally sourced food to reduce transportation emissions, offering refillable water bottles, and asking attendees to consider offsetting their travel-related carbon footprint by donating to nongovernmental agencies in Africa that provide solar cooking stoves and photovoltaic solar panels to power mobile phones. During the meeting, ESCRS launched the Young Ophthalmologists for Sustainability (YOFS)—an international group that aims to engage more doctors in sustainable ophthalmic care.

The issue is important to cataract surgeons and nurses, said David Chang, MD, a cataract surgeon in private practice in Los Altos, California, who has been a leading proponent of sustainable changes. In a recent survey of cataract surgeons and nurses by the Ophthalmic Instrument Cleaning and Sterilization (OICS) Task Force, which he cochairs, 98 percent said they believed that OR waste is excessive and 78 percent felt surgeons should reuse more supplies.⁴

With an eye toward creating a central resource to promote sustainable practices, Drs. Chang, Findl, Shukla, and others launched EyeSustain.org at the American Society of Cataract and Refractive Surgery (ASCRS) annual meeting, on Earth Day 2022. The website (and a companion mobile application) is cosponsored and supported by ASCRS, ESCRS, and the American Academy of Ophthalmology (AAO). It features many helpful resources, including information on sustainability in the clinic and OR, reducing ophthalmic drug waste, global green practices, industry sustainability initiatives, and a section on the general health impacts of climate change, says Dr. Shukla, who chairs the site’s editorial board of 12 early career ophthalmologists.

The section on sustainability in the OR has a calculator that surgeons and practices can use to estimate their carbon footprint. “Then they can really see the impact that they’re having with their current practices,” says Dr. Shukla, who adds that she observes waste in her own hospital. “Every time I’m in the operating room, I generate two bags of trash per cataract surgery, and so if I’m doing 10 cases a day, I end up generating 20 bags of trash. You can very quickly see the impact that you personally are having—a negative impact.”

Additionally, EyeSustain.org provides videos, articles from peer-reviewed and trade journals, a resource library, and other helpful information from the Outpatient Ophthalmic Surgery Society (OOSS) that ophthalmologists can use to advocate for changes within their own practices and institutions. Also included is a link to get involved with EyeSustain. “Every week, at least 10 people reach out to us saying they are not happy with the footprint ophthalmology is creating and want to be involved in the EyeSustain group,” Dr. Shukla says.

The site will continue to evolve, says Dr. Chang, who chairs the EyeSustain advisory board, with coming features including a pledge for eye surgical facilities and institutions to promote sustainability of quality eye care and surgery, and a section on global best practices. “Ophthalmologists all around the world are trying to tackle the same problems, and unless we can share information and collaborate, we’re not going to make substantive changes,” he says.

European Surgeons Instituting Changes

Meanwhile, ophthalmic surgeons worldwide are making efforts to reduce waste and increase sustainable practices in the operating room. In the Netherlands, surgeons perform some 180,000 to 200,000 cataract surgeries per year, says Rudy Nuijts, MD, PhD, vice chairman of the Maastricht University Eye Clinic and past president of ESCRS. “Everybody is convinced that we must do something about climate change, and everybody is also convinced that we must reduce all our waste. But there is a balance between what is still being regarded as safe,” he says. His hospital calculates its greenhouse gas (GHG) emissions as 35 kg of carbon dioxide equivalent (CO₂-eq) per cataract procedure. (Carbon dioxide equivalent is a metric measure used to compare the emissions from various greenhouse gases, including methane or nitrous oxide, by converting them to an equivalent amount of carbon dioxide based on each gas’s global warming potential.) Aravind Eye Hospital in India, by contrast, emits about 6 kg of CO₂-eq per procedure,⁵ while an earlier study conducted at the University Hospital of Wales in Cardiff, United Kingdom, estimated GHG emissions at 181 kg of CO₂-eq per procedure.¹

Sjoerd Elferink, MD, a cataract surgeon at Flevoziekenhuis Almere hospital in the Netherlands, cofounded the Dutch Working Group on Sustainable Ophthalmology. One of their first tasks was to argue against the use of full-length drapes for patients during cataract surgeries because only a tiny incision in the eye is required. This change was endorsed by the Dutch Ophthalmological Society and eventually by the Dutch Society of Infection Prevention in Healthcare.

In his own practice, Dr. Elferink uses a face drape only, has replaced disposable absorbent pads placed under patients’ heads to catch water with reusable towels that can be laundered, and instructs a pharmacist to prepare 1 mg syringes of cefuroxime prior to each cataract procedure, rather than opening a 50 mg vial for each surgery and discarding the balance (approximately 49 mg) as required by the European Medicines Agency (EMA). “From the literature we know that pharmaceutical production and transportation have a very high footprint,” explains Dr. Elferink. “So, you can have a major impact by reducing the waste of medication.”

His practice also is testing a phacoemulsification machine that has a certificate alllowing the cassette to be reused on up to 10 patients. With guidelines in the country recently adjusted to allow bilateral cataract surgery, he also is looking to soon provide that option to reduce emissions generated by patient travel.

Dr. Nuijts’s team has stopped using multiple plastic cups used to cover patients’ eyes postoperatively, sprayers to clean the eye, and gowns for patients, and embraced smaller gowns for staff. They implemented bilateral cataract surgery during the COVID-19 pandemic to reduce physical contact with patients—but, as a bonus, bilateral surgery has reduced carbon emissions by an estimated 25 percent. This is primarily due to fewer hospital visits and less overall travel by patients, he says.

Fighting Outdated Ideas and Moving Forward

Depending on the country, there can be significant barriers to changes in regulations and concerns about infection prevention, Dr. Chang says. Waste can result from following regional or local regulations, or those that govern surgery centers regardless of the type of procedure. Institutions may impose their own policies, too. “So much of this waste is coming from unproven practices, based usually on a perception of safety from a group, such as regulatory bodies, that have a very strong bias,” he says.

“There are practice patterns that we have adopted and accepted…and we don’t know anymore why we accepted them,” adds Dr. Nuijts. “The evidence for doing it is sometimes not there, so we have to go back and reinvent the wheel again.”

Collecting evidence could be a part of the solution. Dr. Vivekanandan and colleagues collected culture samples from phaco tubing used for 20 to 30 cases at a time, representing some 3,800 patients. Not even one tube had a positive growth, he says. Their research has not yet been published.

There also must be cooperation from industry, which currently has motive to sell disposable products and custom packs because of their high profits, Drs. Elferink and Nuijts say. Ophthalmologists could take a cue from other sectors outside health care, suggests Dr. Elferink. For example, Philips is providing lighting for newer terminal buildings at the Amsterdam Schiphol Airport. But the airport contracted for light as a service, not for a set number of bulbs that can burn out and need to be replaced. Therefore, he says, the company has an incentive to produce lights that endure for a long time, and which can be repaired, because it lowers their costs. “We should consider these out-of-the-box concepts to give industry an incentive to make cataract surgery more sustainable,” he says.

Sustainability is not always a topic that is at the top of physicians’ minds, so the first step toward change is education, Dr. Shukla says. She gave a recent Grand Rounds discussion at Columbia on EyeSustain which “was met with immense interest and excitement by everyone from ophthalmic surgeons to basic science researchers to administrators,” she says.

Ophthalmologists and other healthcare professionals should be at the forefront of the movement, Dr. Elferink says. “The climate crisis is a health crisis. There is major scientific evidence for the threats that we are about to face. Healthcare professionals should be in front of everyone telling society what is at stake.” OASC

REFERENCES

1. Morris DS, Wright T, Somner JEA, Connor A. The carbon footprint of cataract surgery. Eye (Lond). 2013;27(4):495-501. doi:10.1038/eye.2013.9
2. Dacones I, Cave C, Furie GL, Ogden CA, Slutzman JE. Patient transport greenhouse gas emissions from outpatient care at an integrated health care system in the Northwestern United States, 2015-2020. J Clim Chang Health. 2021;3:100024. https://doi.org/10.1016/j.joclim.2021.100024
3. Forner D, Purcell C, Taylor V, et al. Carbon footprint reduction associated with a surgical outreach clinic. J Otolaryngol Head Neck Surg. 2021;50(1):26. doi:10.1186/s40463-021-00510-4
4. Chang DF, Thiel CL. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste. J Catarac Refract Surg. 2020;46(7):933-940. doi:10.1097/j.jcrs.0000000000000267
5. Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43(11):1391-1398. doi:10.1016/j.jcrs.2017.08.017